Direct Surgery for Brainstem Tumours

Bricolo, Albino; Turazzi, S.; Cristofori, L.; Talacchi, Andrea

doi:10.1007/978-3-7091-9183-5_25

Cited by 70 publications

(28 citation statements)

References 21 publications

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“…In four series totaling 71 cases where diffuse BSG were biopsied or partially excised, every tumor was a glioma [9,[13][14][15].…”

Section: Biopsies Of Diffuse Gliomasmentioning

confidence: 99%

Diffuse Brainstem Tumors: When is a Biopsy Necessary?

Al¹

1996

Pediatr Neurosurg

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This study addresses the role of biopsies in diffuse pediatric brainstem tumors. Biopsies have been advocated to confirm the diagnosis, to determine the tumor histology, to obtain prognostic information and because they can be done with low risk. Biopsies are opposed because diffuse brainstem tumors are gliomas, the histology does not correlate with prognosis nor with histology at autopsy, clinical and magnetic resonance scans provide prognostic information, biopsies have risks, and the biopsy does not alter therapy nor improve prognosis. The conclusion is reached that biopsies are not indicated in children with typical clinical and magnetic resonance features of diffuse brainstem gliomas.

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“…In four series totaling 71 cases where diffuse BSG were biopsied or partially excised, every tumor was a glioma [9,[13][14][15].…”

Section: Biopsies Of Diffuse Gliomasmentioning

confidence: 99%

Diffuse Brainstem Tumors: When is a Biopsy Necessary?

Al¹

1996

Pediatr Neurosurg

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“…Traditionally, these lesions have been treated with radiation therapy and chemotherapy, and have not been considered appropriate for surgical resection [16][17][18][19][20][21][22][23][24][25][26][27], The majority of current pediatric neurosurgeons base therapeutic intervention on clinical and radiographic data [28]. In the setting of this stereotypical picture, most clini cians now oppose a diagnostic biopsy procedure.…”

Section: Introductionmentioning

confidence: 99%

Intra-Axial Tumors of the Cervicomedullary Junction: Surgical Results and Long-Term Outcome

et al. 1997

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Until recently, intra-axial brainstem tumors were traditionally regarded as surgically inaccessible lesions with a uniformly poor prognosis. However, increasing data indicate that distinct subgroups of brainstem tumors exist that are amenable to surgical intervention. To address this question, we reviewed our experience in the operative management of 39 consecutive patients, in the magnetic resonance imaging (MRI) era, with intra-axial cervicomedullary tumors, in order to determine those factors associated with long-term outcome. Thirty-nine patients (26 male, 13 female) underwent surgery by a single surgeon (F.J.E.) between 1985 and 1994. Mean age of diagnosis was 14 years (range 3 months – 60 years); mean duration of preoperative symptoms was 24 weeks (range 1–168). Twenty patients presented with lower cranial nerve dysfunction and 19 presented with motor and/or sensory dysfunction. All patients were graded according to the McCormick Scale, pre- and postoperatively, and at the time of follow-up. All patients were evaluated with MRI scanning. Twenty-three patients had either previous biopsy or subtotal resection, 13 previous radiation therapy, and 6 previous chemotherapy. The mean time to follow-up was 48 months (range 7–138). Twelve patients underwent gross total resection, 7 near total resection (>90%), 15 subtotal resection (50–90%), and 5 partial resection (< 50%). Histologically, there were 15 low-grade fibrillary astrocytomas, 9 ependymomas, 7 gangliogliomas, 3 anaplastic astrocytomas, 3 juvenile pilocytic astrocytomas, and 2 mixed gliomas. Although the vast majority of tumors were low grade histologically, a higher proportion of the patients with high-grade lesions experienced tumor progression when compared to low-grade tumors (75 vs. 30%). Overall, the 5-year progression-free and total survivals were 60 and 89%, respectively. There was 1 death within the first postoperative month. Preoperative duration of symptoms greater than 15 weeks was associated with a longer progression-free survival. There was a trend for preoperative neurologic grade to predict functional neurologic outcome at follow-up. In summary, intra-axial tumors of the cervicomedullary junction are a distinct subset of brainstem tumors, predominantly of low-grade histology, with favorable long-term progression-free and total survivals following surgical resection. A long duration of preoperative symptoms may indicate an indolent clinical course and a more favorable prognosis. Our data also indicate that early surgical intervention is warranted prior to neurologic deterioration.

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“…But the expertise gained by select groups of neurosurgeons using an essential combination of progress in microsurgical instruments and techniques, skull base surgery, surgical planning with magnetic resonance imaging and image guidance, neuroanesthesia and neurointensive care, and intraoperative monitoring produced significantly better results and outcomes for patients with brainstem lesions. For instance, Bricolo et al 5,6 have published extensive work on brainstem tumors, introducing and discussing different safe entry zones. Similarly, the senior author of this paper (R.F.S.)…”

Section: Discussionmentioning

confidence: 99%

Microsurgical anatomy of safe entry zones to the brainstem

Cavalcanti

Preul

Kalani

et al. 2016

JNS

141

118

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H istorically, the surgical management of intrinsic brainstem lesions has been controversial. The surgical extirpation of focal gliomas, cavernous malformations, or hemangioblastomas within the brainstem has caused heated discussions in scientific meetings and the literature. In 1939, Bailey et al. 3 declared this subject to be a pessimistic chapter in neurosurgery; 30 years later, Matson and Ingraham 26 would still claim such lesions were inoperable. However, in 1971, Lassiter et al. 25 were among the first to advocate surgical intervention. By 1986, Epstein and McCleary reported that surgery was feasible with reasonable morbidity and mortality.15 Concurrent with Epstein and McCleary's report, Raimondi would rationally state that to have the child merely survive (i.e., with severe neurological deficits) is no justification for surgery. 33 The development and improvement of complex skull base surgical approaches and incremental advances in neuroimaging, parallel to image-guided surgery, allowed a few authors to safely and effectively resect lesions in the brainstem. 5,23,32Knowledge of different skull base exposures, gained through laboratory dissections, allows neurosurgeons to approach lesions in the brainstem. Nevertheless, the brainstem, roughly the size of the human thumb, contains a rich concentration of nuclei and fibers in a small sectional area, resulting in a high likelihood of morbidity after manipulation. Awareness of the main safe entry zones on the brainstem is key to reducing morbidity for any lesion that does not emerge to the pial or ependymal surface. Such zones represent entry points and trajectories where eloquent structures and perforators are sparse and where a neurotomy would cause the least possible damage.abbreviatioNs CN = cranial nerve; mini-OZ = mini-modified orbitozygomatic approach; PCA = posterior cerebral artery; P 2 P = posterior P 2 ; SCA = superior cerebellar artery; TAPS = transanterior perforating substance. obJective The aim of this study was to enhance the planning and use of microsurgical resection techniques for intrinsic brainstem lesions by better defining anatomical safe entry zones. methods Five cadaveric heads were dissected using 10 surgical approaches per head. Stepwise dissections focused on the actual areas of brainstem surface that were exposed through each approach and an analysis of the structures found, as well as which safe entry zones were accessible via each of the 10 surgical windows. results Thirteen safe entry zones have been reported and validated for approaching lesions in the brainstem, including the anterior mesencephalic zone, lateral mesencephalic sulcus, intercollicular region, peritrigeminal zone, supratrigeminal zone, lateral pontine zone, supracollicular zone, infracollicular zone, median sulcus of the fourth ventricle, anterolateral and posterior median sulci of the medulla, olivary zone, and lateral medullary zone. A discussion of the approaches, anatomy, and limitations of these entry zones is included. coNclusioNs A detailed understanding...

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Direct Surgery for Brainstem Tumours

Cited by 70 publications

References 21 publications

Diffuse Brainstem Tumors: When is a Biopsy Necessary?

Diffuse Brainstem Tumors: When is a Biopsy Necessary?

Intra-Axial Tumors of the Cervicomedullary Junction: Surgical Results and Long-Term Outcome

Microsurgical anatomy of safe entry zones to the brainstem

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